Single Port Total Laparoscopic Hysterectomy
Chad M. Michener
General Principles
Definition
Single-port laparoscopic (SPL) surgery has also been termed single-incision laparoscopic surgery (SILS) and laparoendoscopic single-site (LESS) surgery.
SPL hysterectomy is performed through a single incision, most commonly placed through the umbilicus.
The incision can vary in size and location depending on the need for intra-abdominal palpation and/or specimen extraction.
SPL hysterectomy may apply to either standard laparoscopic or a robotic single-port approach.
Nonoperative Management
Nonoperative management of conditions that may require hysterectomy (e.g., abnormal uterine bleeding, leiomyoma, endometriosis, chronic pelvic pain, preinvasive and invasive diseases of the uterus and cervix). Consider:
Hormonal therapy (e.g., oral or intramuscular progesterone)
Progesterone-releasing intrauterine devices
Uterine fibroid embolization
Hysteroscopic resection of leiomyoma
Endometrial ablation
Cervical conization (for cervical dysplasias)
Radiation therapy (for cervical and uterine malignancies)
Total vaginal hysterectomy (which is less invasive)
Total abdominal hysterectomy (for very large uteri that would have to be morcellated)
Imaging and Other Diagnostics
Imaging will depend on the indication for hysterectomy. However, pelvic ultrasonography, saline infusion sonography, or pelvic magnetic resonance imaging (MRI) will often be performed for patients considering hysterectomy for abnormal uterine bleeding and leiomyoma.
Diagnostic and operative hysteroscopy should be used to rule out endometrial pathology that can be treated by simple hysteroscopic resection or ablation.
Low-grade endometrial cancers do not need pelvic imaging as a group, but imaging should be individualized based on physical examination and risk of metastasis. High-grade endometrial cancers should have computed tomography (CT) of the abdomen and pelvis and either chest radiograph of CT of the chest.
Presumed early-stage cervical cancers should have pelvic MRI to rule out large tumors or deep cervical wall invasion and a positron emission tomography (PET) scan should be considered to rule out obvious regional and distant metastases.
Preoperative Planning
Consideration should be made for route of specimen removal (vaginal or abdominal) and discussed with the patient.
Prior surgical history is important to consider in deciding on placement of the incision.
Patients with prior mesh placement in the umbilicus may require supraumbilical incision.
If an ostomy is needed (for endometriosis or locally invasive endometrial carcinoma), the stoma site can be used as the SPL access site.
Surgical Management
Proper equipment is essential for the procedure.
Visualization: A 30-degree or flexible-tip laparoscope will aid in avoiding instrument alignment that can cause a loss-of-depth perception. Alternatively, a 30-degreee bariatric length laparoscope will help get the assistants and surgeons hands further apart.
Access: Multiple commercially available ports are available that allow two to three instruments to be used along with a camera at one time.
Triangulation: Articulating instruments can help with triangulation, but are not mandatory.
External instrument clashing: Use of different length instruments (e.g., a bariatric grasper and standard length vessel sealing device) can help limit external instrument clashing.
Suturing: Use of the Endo Stitch device (Ethicon Endosurgery, Cincinnati, OH) allows for easier suturing in SPL.
Intracorporeal knot tying techniques can be learned which helps with this task.
Preoperative work-up is the same as for standard and robotic-assisted laparoscopy.
Positioning
Patient is placed on the operating table on a beanbag (Fig. 8.3.1A) or a foam pad (Fig. 8.3.1B) with buttocks extended an inch or two off of the bed.
Additional intravenous lines and arterial lines can be placed as needed.
Arms should be tucked and padded at the patient’s sides.
Arm trays can be used if the arms extend beyond the bed.
The regular arm boards can also be used as an alternative if they are also locked against the operating table.
A pad or a blanket should be placed over the patient’s chest and either 3″ cloth tape or a chest strap should be used to maintain position in steep Trendelenburg (Fig. 8.3.1C).
See Figure 8.3.2A–C.
Figure 8.3.1. Patient position. A: Positioning on a foam pad with hands padded and chest strap in place. B: Positioning using a bean bag with arms tucked, all pressure points padded and chest strap in place. C: Full Trendelenburg position during procedure.
Figure 8.3.2. Flexible laparoscope and hand positioning straight instrumentation. A: The flexible laparoscope allows you to “see around corners.” B: Position of hands working on the right side of the pelvis. C: “Crossing over” with left hand during left-sided pelvic dissection.
Approach
Typical approach uses the umbilicus as the entry point into the abdomen.
Infraumbilical, transumbilical, and Omega incisions are the most commonly used incisions.
Alternative sites can be used if there is history of umbilical surgery or mesh.
In patients with prior abdominoplasty or myocutaneous flap harvesting, the umbilicus is in its native location on the abdominal wall, but may have underlying mesh associated with it.
An ostomy site can be used for access if ostomy is planned for advanced cancer or endometriosis.
Closure of the vaginal cuff may be performed laparoscopically or transvaginally.
The lowest risk of vaginal cuff dehiscence was noted with transvaginal closure in some studies1:
TLH laparoscopic suturing 0.86%
TLH vaginal suturing 0.3%
Abdominal hysterectomy 0.21%
Vaginal hysterectomy 0.18%
Procedures and Techniques (Video 8.3)Anesthesia and positioning
Following general anesthesia, the patient is placed in the low lithotomy position with arms tucked and padded at the sides and a strap placed across the patient’s chest.
Tolerance of steep Trendelenburg position can be tested prior to prepping the patient.
Prepping and draping
Vagina, perineum, and abdomen are sterilely prepared and the patient draped.
Antibiotics and bladder drainage
The appropriate intravenous antibiotics are given and a Foley catheter is inserted into the bladder.
Manipulation of the uterus
The uterine manipulator is placed (if being used). In endometrial cancer or hyperplasia consider cauterizing fallopian tubes laparoscopically prior to placement of manipulator.
Local anesthesia
We use 0.25% or 0.5% bupivacaine injected circumferentially around the umbilicus for local anesthesia prior to making the incision (Tech Fig. 8.3.1A).
 Tech Figure 8.3.1. Abdominal access and port placement with the GelPOINT®. A: An “umbilical block” using 6 to 10 mL of bupivacaine. B: Grasp the umbilicus at 3 and 9 o’clock with Allis clamps. C: Incise the skin 1.5 to 2 cm across the edges and trough the base of the umbilicus, then grasp and transect the fascia, then the peritoneum to 1.5 to 2 cm. D: Place an s-retractor to assist with placement of the ring of the retractor sleeve. E: Roll outer ring of the sleeve inward to tighten. F: This will expand the incision and protect the wound. G: Place the instrument shield. H: Place three to four trocars through the gel starting wide and aiming each to center of gel. I: Placement of the gel cap onto the ring. |
Abdominal incision
Typical transumbilical abdominal entry is carried out by grasping the edges of the umbilicus at 3 and 9 o’clock with Allis clamps (Tech Fig. 8.3.1B), incising the umbilicus ∼1.5 cm in the midline through its base (Tech Fig. 8.3.1C), replacing the Allis clamps just below the skin at the base of the umbilicus and everting the umbilical skin outward, incising the fascia with curved Mayo scissors, grasping the peritoneum with hemostats and entering the peritoneum sharply. The peritoneum and fascia are the extended with electrocautery.
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